Part IV in this series discusses expanding HIM’s visibility and enhancing organizational processes via authorization denial management.
In my prior article, I discussed the value of payer policy management, and mentioned that “no authorization” denials represent 10-15 percent of all denials. This focused denial category presents another opportunity for health information management (HIM) professionals. HIM can monitor such denials in a process improvement role.
Many organizations perceive denials management as a back-of-the-house process, but all authorizations are a front-of-the house responsibility. For physician practices, denials for lack of authorization represent 80 percent of the total, so working with your hospital-employed providers to avoid such pitfalls by capturing the authorizations required at the time of scheduling the service will mean “cha–ching” – and you know that’s what your CFO wants to hear.
So, what do we need to do?
Sitting in access at the hospital should be someone with some clinical expertise, such as a coding professional, who knows that this is a normal chain of events. In the physician office, the authorization specialist can quiz the physician to ensure that authorizations are captured for the commonly anticipated services.
Some inpatient procedures require authorizations as well. Since eligibility may change during a given stay, the workflow for scheduling should include re-checking eligibility throughout the stay, and also obtaining authorizations for any new procedures planned.
According to an Healthcare Financial Management Association (HFMA) article, up to 65 percent of denied claims are never appealed. Focusing attention on denials for lack of authorization and reducing those denials through process improvement will reduce the labor costs to research and appeal denials, as well as increase revenues – and that’s what we’re going for.
Good luck!
Programming Note: Listen to Rose Dunn report this story live today during Talk Ten Tuesdays, 10 Eastern.
In the FY 2026 Inpatient Prospective Payment System (IPPS) and Long-Term Care Hospital Prospective Payment System (LTCH PPS) proposed rule, the Centers for Medicare &
EDITOR’S NOTE: On the morning of Jan. 22, major American news outlets were reporting the story of a huge artificial intelligence (AI) technology partnership. The
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